This is a blog by a former CEO of a large Boston hospital to share thoughts about negotiation theory and practice, leadership training and mentoring, and teaching.

Sunday, December 21, 2008

What if?

Just thinking, along the lines of a New Year's resolution. What if all of the hospitals in the Boston metropolitan area -- academic medical centers and community hospitals -- decided as a group to eliminate certain kinds of hospital-acquired infections and other kinds of preventable harm? And what if they all committed to share their best practices with one another and to engage in joint training and case reviews in these arena? And what if they all agreed to publicly post their progress on a single website for the world to see?

Let's start simply. My candidates:

1 -- Eliminating central line infections (Metric: The number of CLIs, as defined by the CDC. Goal = 0)2 -- Adopting the IHI bundle to help avoid ventilator associated pneumonia (Metric: Percent compliance with the bundle. Goal = 100%)3 -- Adopting the WHO protocol developed by Brigham and Women's Hospital's Atul Gawande for surgical procedures (Metric: Percent of surgical cases in which the pre-op, time-out, post-op checklist has been followed. Goal = 100%)

The medical community in Boston likes to boast about the medical care here, but we don't do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.

18 comments:

The key is to simplify. In the ER (where most of these things are initiated), nurses and doctors always have several patients that they are seeing. I think that nearly all the ER employees that I've come across want to do a good job, but we get bogged down with regulations and initiatives that don't take into account the work required to implement them.

Every new initiative that you try to put into effect requires training, supplies, and often times extra personnel to assure that it is accomplished effectively.

So if you want to start these plans, make sure that every effort is taken to simplify the process as much as possible. Put materials together in packages so that nurses or techs don't have to go hunting and try to remember all the different supplies to get. Simplify implementation plans so that long and complicated algorithms aren't required. Train a few "super users" who become experts in the process and can help others when it comes time to perform the procedures.

As an ER nurse, few things are worse than trying to remember all the steps for some new initiative when we are in the middle of caring for a very complicated and critical patient (such as those who require central lines or ventilators.

So to summarize a long comment: in the middle of your quality initiatives which sound great, don't forget that actual people have to implement them in the middle of very busy work schedules, so keep it as simple and easy as possible.

Perhaps other hospitals are waiting for BIDMC to take the fall for imperfect rates of success. Perhaps the real challenge of systemic changes in healthcare delivery will just go away, and we can continue doing business the way that we know how. Status quo is a comfortable place, and enabled when people choose hospitals without regard for transparency. (There is an important analogy in recent financial debacles).

But it isn't going to happen. BIDMC has committed itself - across all levels of the institution - to doing things better. Now. Publicly. Standards of operation are shifting quickly and, as in natural selection, it may be the fast and nimble rather than big or static that thrive. (Toyota analogy, anyone?)

To the important comment by the ER nurse above: perhaps the most significant contribution to any introduced initiative is to speak up if something isn't working. Especially if it adds complications to workflow. No quality initiative should make life more difficult - at least in the long run. 'More work' is not quality improvement.

You could help eliminate central line infections by limiting overuse of central lines. If your nurses and doctors and plebotomists used smaller needles and were more careful with patients' veins than you would not need so many central lines. Many of them are careless and there are not small enough needles on their carts.

Along the lines of Dave, I'll one-up you: What if every hospital collaborated not just with each other but also with health insurance providers, ambulance companies, and the Boston public health department to create an open source online database of who to call for what, so that patrons and vendors can visit this one-stop social network or wiki rather than visiting each partner or partner's website for information?

For instance, I'd love to know for a given insurance level, which hospital has the most number of available beds for a given surgery. And how former patients rated those hospitals and surgeons. And I want that info stat in one place.

Let's start one small step at a time. Hence the idea in this post. I don't think what I suggest should be threatening in a competitive way for any hospital, and it would show the public that we are all serious about reducing harm and avoiding at least this set of unnecessary costs.

There are some political aspects to your idea that I fear would cause it to be DOA, but the idea of pooling regional resources and knowledge to train staff and advance best practices across hospitals is a good one and entirely doable. Not only that, it would allow all participants access to higher quality patient safety information at lower overall costs, through eliminating duplication of effort at each hospital. And, lest the stronger (read, richer) hospitals think they "know it all" already, they can refer to the recent Globe articles.You could even give the website a fancy name, like the Boston Center for Patient Safety.

Transparency related to hospital infections, especially those identified by Mr. Levy, is required in several states including, at some point in the future, Massachusetts. Several hospitals in projects in Michigan, Rhode Island and organized by IHI, report significant improvement and in some cases elimination of some infections. What they don't do however is make public actual rates using the same numerators and denominators so consumers can be certain comparisons are valid. Outside verification would also help especially when such a worrisome problem is claimed to be eliminated or significantly improved. Consumer Reports would welcome the opportunity to publish reliable information from hospitals who commit to such a New Years resolution. Such a small but significant step would hopefully start a new relationship between consumers and hospitals.John Santa Director, Consumer Reports Health Ratings Center

All said, competitiveness compromises cooperation between individuals, and the same applies to organizations. It would be great if all took the high ground, but this is unlikely in a saturated environment. Many years ago in biology, they called this the 'tangled bank hypothesis'. Where resources and competition are dense, specialization is a winning strategy. BIDMC can't depend on cooperation or regulation. Quality has to happen from within.

Do we ever have cases where staff in different hospitals openly share what they learn about a particular problem so others can adopt the improvements? Or even share their thoughts in open, joint troubleshooting sessions? Like an open "Grand SPIRIT" call-out?

For instance, has BIDMC shared the methods it developed for minimizing CLIs? Having received four of them during my treatment, I have a particular fascination with that one.

I sure love the idea of cooperating across hospital lines. And I can't imagine anyone with the spirit of an Albert Schweitzer who'd say no. (And yeah, that's the spirit I want in my medical community.)

Dave,The sad part of it is that in my experience, the lower level staff in departments of different hospitals DO cooperate. For instance, if one of the hospital laboratories had an emergency need for a test reagent, other hospital labs would lend it. Or if there was a question about the reliability of an instrument, they would gladly test a few specimens for us, or share how they solved a certain problem, or whatever - and vice versa.This "geurilla cooperation" took place below the level of the administrators (but at manager level and below) and probably would not have been condoned at higher levels. After all, the hospitals were all trying to take market share from each other. Welcome to our wonderful American system of health care.

Wonderful idea to share best practices between hospitals...that would reinforce an idea that hospitals truly put patients before profit and competition. Unfortunately every time I ask for a best practice policy or order set from our local competitor hospital...I am ignored unless I keep pushing. Finally one of the managers asked me is she was allowed to share info. When Hospitals put patients first they will share any best practice any time.

I'll repeat my comment that we all ought to act as Albert Schweitzer would act. Can we imagine him saying no to such a request?

I don't want to sound righteous here, as I sometimes may. I'm inviting us all to look at what factors would have any of us NOT agree to such a request, because those factors are surely a cause of ineffectiveness in American HC. And I'm pretty sure not a one of us went into HC with that end in mind.

Sharing information between hospitals has always been difficult. In a past career I was a therapist at a large hospital in Chicago and was doing some research on what other hospitals provided as far as group therapy for inpatient psych patients. About 50% of the hospitals I called were unwilling to share anything. It amazed me that even information that could aid patients in the city would be so coveted. We in healthcare seem to be too concern about market share and not patient care in this respect.

What if someone designed a small handheld device that was capable of capturing individual patient care by using a uique informaton system made up of sensors and digital imagery. Than having the ability to download accurate, timely individual patient data into the patient's databases. This would take the generic information collected by information systems prominently in use in healthcare today, and refine that information into individualized personalized data provided in a timely manner to give a more complete and accurate picture of what is involved in individual health delivery. The mobility of the handheld device would free up health professionals to get closer to the patient and customize the service to better suit the needs of each individual patient, creating both a safer and more satisfying process of health delivery.I have been a nurse for almost fifty years serving my patients and watching the changes in healthcare delivery.Almost two decades have gone into thinking through the process behind my invention and in 2008 I achieved patent for the invention. When it becomes successful, I believe it will play a part in changing the way we deliver today, and help put the care and safety back into healthcare delivery.Thank you providing this valuable blog space.Pamela F Nye

Yes, we need to cut down on line related infections. The comment about using smaller needles was uninformed. We usually put in central lines during a crisis, to use pressors and have multiple ports. We use PICC lines in non crisis situations when we anticipate multiple draws. By nature, procedures done emergently tend to be messier and lead to more infections. HOWEVER, it is still important to cut down on line related infections. As Braden suggests, 'iniatives' such as these require resources. I am all for smart pre-packaging, check lists and sharing of resources amongst hospitals. In addition to training, money, and "super users", time must be given to make changes. If a change is sensible, efficient, and easier than the old it will be implemented. Additionally, even if the new way is hard, if the benefit is obvious, people will make the change.

There is a lot of great data on this and Peter Pronovost has done fantastic work. It may seem obvious but given the results obvious NOT= doing.I talked about it here I find it hard to understand why there is resistance to simple but effective ideas. Is it the sense of shame that using something so simple is a poor reflection on the intelligence and capabilities of those using such tools. No one thinks of pilots in those terms and I bet Sully Sullenberger of US Airways Hudson splash down fame used a checklist and no one thinks any less of him!